Telepsychiatry in Australia: A Scoping Review

Introduction

Telehealth involves the use of information technology (IT) to deliver healthcare services, including clinical assessment, care, and health-related support across geographical distances.^{1 -3} Telehealth provided by psychiatrists is known as telepsychiatry.^4,5 Telepsychiatry may involve synchronous methods (telephone, videoconferencing) or asynchronous methods (e-mail, web-based systems, and mobile applications). Most commonly, telepsychiatry denotes 2-way, live psychiatric consultations. ⁶

Telepsychiatry began in the 1950s as a means to expand clinical services to distant geographical areas. ⁴ In the 1960s, several services were implemented in the United States. ⁷ In the following decades, various telepsychiatry programs developed globally. By 1998, an international survey identified 29 programs, with 25 in the United States, 1 in Canada, 1 in England, 1 in Norway, and 1 in Australia. ⁷ The first Australian telepsychiatry service began in 1993. ⁸ By 2001, there were 36 telepsychiatry programs across Australia. ⁹ Facilitated by advancements in communication technologies that enable high-quality videoconferencing at reduced costs, the COVID-19 pandemic greatly stimulated the uptake of telepsychiatry. ¹⁰ A global survey found that more than 90% of mental health professionals from over 100 countries engaged in telehealth. ¹¹ Many countries also made regulatory and funding changes to allow tele-psychiatric care. ¹²

Australia faces substantial challenges in psychiatric care provision due to the vastness of the continent, the relatively small population, the remoteness of many communities, as well as the reliance upon a national telecommunications network to maintain connectivity and provides healthcare, government and other public services, and business. The early literature on Australian telepsychiatry services emerged in the 1990s.^{13 -15} Subsequently, telepsychiatry has grown across Australia. ⁹ Similar to other telehealth services, telepsychiatry mostly involved videoconferencing between hospital-based clinicians and patients in rural and remote areas, and it was aided by the improvement in broadband capacity through the construction of the National Broadband Network (NBN). ¹⁶ During the COVID-19 pandemic, telepsychiatry formed part of the nation’s mental health response as the Australian Government expanded telepsychiatry availability in the Medicare Benefits Schedule (MBS) in early 2020. ¹⁷ Since then, rapid uptake of telepsychiatry has been observed.^{18 -20}

Several systematic reviews and meta-analyses have examined the outcomes, effectiveness, and cost-effectiveness of telepsychiatry in an international context.^{21 -23} However, searches of the Cochrane Database of Systematic Reviews, PROSPERO International Prospective Register of Systematic Reviews, and Joanna Briggs Institute Systematic Review Register in December 2022 found no relevant Australia-specific review. Many new research findings on service usage and other aspects of telepsychiatry in Australia have emerged during the pandemic. Although there have been opinion pieces, speculative articles, and scholarly discussions on its ongoing role, a full review of the current evidence base is lacking.

Unlike systematic reviews that tend to focus on the effectiveness of interventions, a scoping review allows a broader approach to answering a wider range of research questions. ²⁴ It can ascertain the extent of, and approach(es) used, in the current research on a given topic^24,25 concerning a specific context or location, such as Australia. ²⁶ Adopting a country-specific approach is appropriate, since understanding a country’s particular circumstances is crucial in the evaluation of mental health policies and plans. ²⁷ The objective of this scoping review was to systematically map and explore the existing literature on telepsychiatry in Australia. It sought to identify key research priorities to advance relevant policy and practice.

The research questions (RQs) were:

Materials and Methods

This scoping review was conducted according to the methodology described by Arksey and O’Malley, ²⁵ Levac et al, ²⁸ Peters et al, ²⁴ Peters et al, ²⁹ and the Joanna Briggs Institute Reviewer’s Manual. ³⁰ The review protocol was pre-registered on the Open Science Framework (https://osf.io/mfpsv). It is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Scoping Reviews (PRISMA-Scr, see Supplemental material 1). ³¹

Results

We identified 3339 searches from the databases, of which 1000 were duplicates. Five additional articles were identified through a hand search of reference lists. The title and abstract screening identified 122 publications. Full-text screening resulted in 96 eligible publications (Figure 1).

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Figure 1.

PRISMA flow diagram of systematic search and study selection.

The articles were published in 29 different journals, the 3 most frequent being the Journal of Telemedicine and Telecare (n = 31, 32.3%), Australasian Psychiatry (n = 26, 27.1%), and the Australian and New Zealand Journal of Psychiatry (n = 9, 9.4%). Of note, 31.3% of all articles were published since 2020, largely during the COVID-19 pandemic (Figure 2).

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Figure 2.

Number of accepted articles on telepsychiatry in Australia per year from 1994 to 2022.

The key findings of this scoping review are summarized in Table 1. Detailed results are presented in the following subsections for the research questions. The full extraction of characteristics and results of sources of evidence is available in Supplemental material 5.

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Table 1.

Key Findings of the Scoping Review According to the Research Questions.

Research question	Key findings
RQ1. What were the types of telepsychiatry research conducted in Australia?	• The most common study types were quantitative studies and descriptive service reports • Few experimental, qualitative, or mixed methods studies • Few economic analyses of telepsychiatry services
RQ2. What types of telepsychiatry services were implemented in Australia?	• Most earlier services involved public health providers • Medicare-reimbursed telepsychiatry by private psychiatrists predominate since 2020 • The most frequent mode of telepsychiatry was videoconferencing
RQ3. What was known about the level of usage of telepsychiatry in Australia?	• Few studies examined usage levels and patterns over time • Early, regional services reported growth in usage • Prior to 2020, Medicare-funded telepsychiatry formed a tiny fraction of all Medicare psychiatric consultations • After the Medicare telehealth item expansion in 2020, a considerable increase in telepsychiatry usage was reported
RQ4. What were the reported quantitative outcome measures used?	• Few studies reported clinical outcomes of telepsychiatry using validated instruments • Comparisons with face-to-face consultations did not show significant differences in diagnostic accuracy and outcomes • Cost analyses of early services demonstrated cost savings with telepsychiatry • No cost analysis for Medicare-funded telepsychiatry
RQ5. What were the reported perceptions about telepsychiatry in Australia?	• Four main themes were identified • Patient (and caregiver) needs: improved access and flexibility; cost-saving; acceptance and satisfaction • Clinical care: rapport-building; issues with mental state examination; improved outcomes; safety and risk concerns • Service sustainability: administrative support; costs and funding; providers’ willingness to use telepsychiatry • Technical capability/capacity: need for infrastructure, devices, and technical support; cybersecurity and medicolegal issues
RQ6. What were the research gaps for telepsychiatry in Australia in the literature?	• Patient perspectives and engagement • Measurement of effectiveness and quality of care • Clinical practice: clinicians’ preferences; skills training; clinician-patient interactions • Health economic evaluation • Usage trends and patient profiles • Technology-related: new devices and safe use

RQ1: Types of Research

Seventy-six publications were full articles, while the remainder were correspondence (n = 9), abstracts (n = 5), editorials (n = 3), commentaries (n = 2), and a book chapter. After excluding expert opinions (n = 14) and reviews (n = 6), the most common study types were quantitative studies (n = 43) and description of telepsychiatry service reports (n = 18). Retrospective observational studies were the most prevalent quantitative studies (n = 20). There were 3 quasi-experimental studies and no clinical trials, small numbers of qualitative studies (n = 7) and mixed methods studies (n = 5), and 4 case reports.

There were 76 papers that reported established clinical services. Thirty-two articles were related to nation-wide telepsychiatry. For states and territories, most papers came from New South Wales (NSW, n = 19), South Australia (n = 18), and Queensland (n = 15, Figure 3).

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Figure 3.

A heat map of Australia representing the number of articles on telepsychiatry clinical services and studies conducted in each state and territory. Articles reporting telepsychiatry at the national level are included in the count for each state and territory.

RQ5: Perceptions About Telepsychiatry

Based on the Framework for Telehealth Evaluation in Australia, four main themes were identified: patient (and caregiver) needs, clinical care, service sustainability, and technical capability/capacity (Figure 4).

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Figure 4.

Main themes and subthemes of perceptions about telepsychiatry in Australia from the reviewed publications. Numbers in brackets indicate number of publications coded for the subthemes.

Patient (and caregiver) benefits

Improved access to services was reported by patients,^37,59,60 rural clinicians who were the referrers, ⁶¹ and telepsychiatry providers.^62,63 Telepsychiatry allowed urgent assessment for remote areas.^{53,64 -66} Patients could be seen in their own setting or close to home.^67,68 Thus, telepsychiatry reduced the need for rural patients making stressful travel to regional hospitals.^{37,69 -71} For Australian-based international telepsychiatry, time differences across different time zones might impair access to the service. ⁷²

Telepsychiatry gave patients more flexibility and greater control over the consultation locale.^59,69 They could choose to move out of view of the telehealth platform temporarily if they wished. ⁷³ In contrast, rural referrers to a pediatric telepsychiatry service in NSW observed a lack of flexible availability of the service. ⁷⁴ Time/cost-saving issues were identified in only a few papers and included the avoidance of traveling costs,^37,75 and the absence of extra fees for the telepsychiatry service. ⁶⁶

Some papers reported a high level of patient and caregiver acceptance^13,72,76 and satisfaction.^48,65 However, patient resistance was a barrier in a Victorian telepsychiatry program. ⁶² Cultural appropriateness, especially with Aboriginal or Torres Strait Islander people^37,62,77,78 requires better understanding ⁷⁷ and the use of culturally sensitive interviewing techniques. ³⁸

Clinical care

Some positive perceptions included: caregivers’ reports of good rapport and engagement ⁶⁵ ; patients’ feeling they were treated respectfully ⁷⁹ ; being listened to; and freedom to talk ad hoc during the consultations. ⁸⁰ Nevertheless, clinicians sometimes reported difficulties in engaging patients, building rapport, and conveying empathy.^{47,59,67,81,82} Sometimes, patients felt more inhibited ⁶² and isolated ⁵⁹ and perceived the interviewer as “dull” or “boring” on video display. ¹³ There was 1 report of a psychotic patient developing delusional beliefs toward the interviewer. ¹³ From a psychotherapeutic perspective, impact on therapeutic alliance and emergence of negative transference were postulated. ⁸³

There were reservations regarding telepsychiatry’s inadequacy compared with face-to-face consultations.^8,62,65,82 Mental state examination was limited,^69,72 as nuances of mental state could be lost, ⁵³ including nonverbal cues, affective prosody, and other subtleties.^74,83,84 Telepsychiatry might be inappropriate for patients with significant hearing and visual disabilities,^78,79,81 children under five ⁷⁴ and young patients with psychopathologies such as anxiety and inattention. ⁶⁷ Telepsychiatry might be problematic for insight-oriented dynamic psychotherapy. ⁸⁵ A hybrid approach, with a planned and structured transition from the initial face-to-face session to subsequent telepsychiatry, was suggested.^63,83,86

Telepsychiatry provided a safe interview environment ⁵³ avoiding the risks of travel ⁸² and infection.^63,84 However, there were also safety and risk concerns.^67,81 The clinician lacked the means for effective engagement with an unstable patient. ⁸³ A case report described the difficulty of safely conducting a hyperventilation exercise with an anxious patient through telepsychiatry. ⁴⁷ The need for a proper safety plan was mentioned. ⁸⁴

Positive outcomes included improved clinical care and reduced admissions.^62,78,87 Patients concurred that telepsychiatry helped their treatment. ⁴⁸ Telepsychiatry enabled continuity of care when face-to-face consultations were disrupted.^81,88 Participation of family members who otherwise would not have attended appointments in home-based telepsychiatry illustrated its capacity for more comprehensive care. ⁶⁷ However, some observed less family involvement in telepsychiatry. ⁷⁴ Telepsychiatry could potentially function as virtual home visits, allowing greater insight into a patient’s psychosocial milieu. ⁶⁹ Finally, clinicians providing telepsychiatry services to rural patients might lack local knowledge.^74,89

Service sustainability

Under the theme of service sustainability, managerial support was important in the success of a telepsychiatry service.^{8,37,73,78,90 -92} The service model should be well-defined,^91,93 coherent with organizational values, ⁹⁴ and embedded as part of usual practice. ⁶⁰ Streamlined systems were needed for booking, scheduling, prescribing (such as an e-prescribing system), billing, and reporting.^78,81,84,91 Communication with clinicians on telepsychiatry availability was important.^44,94 For some services, the inclusion of a telepsychiatry facilitator or coordinator was helpful.^68,95 Telepsychiatry also contributed to more equitable distribution of mental health resources to remote and rural area. ⁹⁶

High costs were an early concern. ⁸⁵ However, infrastructural and technical advances have led to increasingly affordable costs. ⁹⁷ Funding for services was also an issue, ⁷⁵ especially for early services. ⁷¹ As Medicare subsidies were introduced, ⁹⁸ telepsychiatry was gradually perceived as cost-saving.^{51,70,75,77,78,87,99} Telepsychiatry helped ensuring private practice business sustainability when face-to-face consultations were restricted during lockdowns.^81,88

Lack of telepsychiatry knowledge and skills was a barrier among clinicians,^37,59,83,92 and was described as a lack of “telehealth culture.” ⁷⁸ Telepsychiatry-related procedures, such as scheduling, ⁴⁸ were perceived as extra burdens.^8,37 Staff training helped improving acceptance of telepsychiatry. ¹⁵ Telepsychiatry was also widely recognized as improving clinician efficiency.^62,78,79,99 Potential downsides were increased fatigue due to long screen time, sedentary behavior, ⁵⁹ and blurred work-life boundaries. ¹⁰⁰

Rural telepsychiatry referrers reported positive experiences, particularly in reducing isolation and improving access to specialist support.^{38,61,68,75,79,89,94,101} However, support was not uniform ⁹⁴ and some local rural workers felt devalued. ⁸ Some providers found that telepsychiatry was convenient^59,60 and improved communication. ⁶² Nevertheless, conservatism ⁹³ and resistance ⁶² were also reported as hurdles to implementation.

Technological capability/capacity

This theme encompasses the availability and use of technology as well as the potential complications of its use. There was a lack of IT infrastructure accessibility for psychiatrists,^8,62,67 including portable devices.^81,83,89 Patients may also lack basic devices such as private telephones, ⁶⁶ especially among patients in rural and remote areas,^70,87,102 Aboriginal or Torres Strait Islander communities, ⁷⁷ and elderly patients. ⁸⁷

Audio and visual difficulties due to technical limitations or insufficient technical support, particularly for videoconferencing, were the commonest technical issues.^{37,47,62,63,65,69,72,79,82,99,101,103} The use of technical jargon and the lack of user-friendliness were other drawbacks.^74,78 However, technical improvements led to perceived ease of use^78,97 and satisfaction.^48,71,73,75 Difficulties with security firewalls, platform preferences, and compatibility, especially in government organizations, were also mentioned. ⁸⁷

Access to a network with adequate bandwidth ensured good transmission quality. ⁸⁵ Connectivity problems were cited both in early publications^75,82 and in more recent papers, especially in rural and remote areas.^66,70 This issue persisted during the COVID-19 pandemic.^63,65,67

Concerning security and medicolegal issues, privacy and confidentiality were mentioned,^{47,59,63,72,78,79,82,83,98} with special concerns about Aboriginal and Torres Strait Islander peoples. ³⁷ Privacy to practice in a quiet and confidential location was essential. ⁶⁹ Additionally, cybersecurity concern^70,72,81 warrants the use of licensed, secure videoconferencing platforms. ⁸³ Medicolegal issues such as consent, prescribing rights, fee charging, and liability issues were raised.^82,83,98 Assessments under the Mental Health Act ⁷¹ and issuing detention orders ⁹⁸ through interstate telepsychiatry required accreditation of the clinician in both states. Concurrent registration in each country (patient/psychiatrist) was also required for international telepsychiatry. ⁷²

Discussion

In this scoping review, we systematically searched major databases for all peer-reviewed publications related to telepsychiatry in Australia from 1990 onward and identified 96 publications. There was a noticeable surge of publications during the COVID-19 pandemic. Telepsychiatry, mostly in the form of videoconferencing for general consultations, was used in all states and territories, for various patient populations, and clinical conditions. We discuss the review findings in two broad areas: research methodologies and telepsychiatry service trends, highlighting the pre- and post-pandemic differences whenever relevant.

Many included papers were narrative descriptions of telepsychiatry services, especially in the early period. While they were useful to inform the initial development of telepsychiatry, they could not address pertinent research questions that require more rigorous methodologies. Many were quantitative, retrospective studies, with only very few involving experimental elements. Randomized trials of telepsychiatry have been conducted in several countries,^{111 -113} but not in Australia. When clinical trials are not feasible, quantitative research that employs a “natural experiment” design, such as interrupted time series, might be feasible.^114,115 Recent papers researched publicly available Medicare data.^{18,41 -46} Analyses of Medicare reimbursement data continue to provide insights into the impact of policy decisions on the availability of telepsychiatry options.

There were few qualitative studies. While quantitative studies provide objective information on telepsychiatry-related research questions, they cannot provide in-depth and more nuanced explanations for the qualitative success or failure of a service. It is, therefore, necessary to explore the organizational contexts, behavioral patterns, and social interactions that are involved in telepsychiatry. ¹¹⁶ Additionally, mixed methods approaches, which integrate qualitative and quantitative investigations, may further improve understanding of complex healthcare interventions such as telepsychiatry. ¹¹⁷

There were very few health economic evaluations of Australian telepsychiatry services. All identified studies were conducted more than 10 years ago and focused on local or regional services.^{48,54 -56} For Medicare-funded rural and remote private practice telepsychiatry, only 1 study reported that the costs for videoconferencing items formed just 0.06% of the costs of all psychiatric consultations from July 2002 to June 2011, without further analysis of the costs incurred. ⁴⁰ All 4 earlier studies attempted cost-minimization analysis by examining cost savings with telepsychiatry in comparison to face-to-face consultation. Given the absence of actual effectiveness data, cost-minimization analysis may be a suitable alternative to cost-effectiveness analysis for telepsychiatry in Australia. This is given that telepsychiatry has so far shown effectiveness largely equal to face-to-face consultation.^22,23,118

Earlier services for rural and remote areas were run by public sector providers such as major public hospitals, often in collaboration with healthcare workers in rural services. The inclusion of telepsychiatry into the Medicare scheme in the early 2000s saw the entry of private practice psychiatrists, but their involvement remained low in the following years ⁴⁰ until the pandemic arrived. ²⁰ This shift has been a boon for telepsychiatry research in Australia, as it provides a trove of usage data at the national level, unparalleled by previous service data at local and regional levels, and indeed, unique internationally. From the clinical service perspective, although most of the new telepsychiatry items were made permanent, ¹¹⁹ it remains to be seen how well telepsychiatry can be fully integrated into private psychiatry practice.

The 4 main themes of perceptions of telepsychiatry in Australia identified: patient (and caregiver) benefits, clinical care, service sustainability, and technology capability/capacity largely align with the groupings of criteria and measures for key dimensions in the original Framework for Telehealth Evaluation in Australia. These themes resonate with the findings of qualitative studies on telemedicine in Australia during the COVID-19 pandemic. Reduced costs, ¹²⁰ improved access^120,121 and convenience^120,122 are key benefits for patients. Clinicians from other specialities ¹²² and patients ¹²⁰ also perceived rapport building and communication as important considerations and possible obstacles of telemedicine. Psychiatrists’ concerns regarding challenges with mental state examination and certain psychopathologies are unique to the discipline. Yet these ideas also correspond to the unease with inadequate examination and patient selection voiced by other clinicians. ¹²² A study involving general practitioners highlights several issues relevant to service sustainability, namely, financial and business pressures, logistical changes to existing services to incorporate telemedicine consultations, and the importance of clinician attitudes and experiences in shaping the use of telemedicine. ¹²³ Finally, technical problems, such as limited connectivity, are also an issue. ¹²⁰ Our framework might be a useful template for the development of qualitative research questions on telepsychiatry perceptions in Australia.

Some identified research gaps warrant mention. In exploring patients’ acceptance of telepsychiatry, the focus should not only be on technological characteristics. Patients’ social environment should also be considered, as the level of social support contributes to user acceptance.^124,125 Regarding the clinical practice of telepsychiatry, in terms of clinician-patient interactions, we should identify useful skill sets for conducting online interviews and effective strategies for the inclusion of telemedicine interview training in medical education. ¹²⁶ We should also examine the implementation process of telepsychiatry services to understand how a complex and relatively new intervention can be “normalized” as part of routine clinical practice. ¹²⁷

This scoping review is the most comprehensive review of all peer-reviewed papers on telepsychiatry in Australia to date (2023). It offers an overview of telepsychiatry development in the country and provides the background for further research. This body of evidence can also serve as a useful reference for policymakers and clinicians in other countries, especially on the use of telepsychiatry to improve access in rural and remote areas and funding for large-scale telepsychiatry services. Further research could include usage trend analysis, clinician engagement and feedback, and economic evaluations, among others. Some study limitations need to be considered. In restricting the inclusion of sources to peer-reviewed publications, “Grey Publications” such as government reports were not included. This might have reduced the amount of data for synthesis. Despite employing a comprehensive search strategy, some publications might still have been missed. Given the diverse evidence sources, a critical appraisal of individual sources was not done. As this review focused on Australia, its findings might not be directly generalizable to other countries, especially those with very different healthcare funding and organization.

In conclusion, there is considerable evidence base on telepsychiatry in Australia, suggesting that it is a feasible mode of care. As telepsychiatry is being made more widely available, it is especially important to examine issues such as usage trends, integration into existing services, and economic evaluations to inform policy decisions. With careful consideration of local contexts and appropriate adaptations, analysis of the Australian experience could also contribute to the advancement of the practice of, and research into telepsychiatry internationally.

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